LVAD

Left Ventricular Assist Devices LVAD

Left Ventricular Assist DevicesLVADNorth Country EMS Program Agency3/21/12ObjectivesDescribe indications for and functions of ventricular assist devices (LVAD)

Differentiate assessment findings of patients with LVAD from other emergency patients

Outline treatment and transport options for care of patients with LVADLeft Ventricular Assist DeviceLVADBridge to transplantIndications for LVAD:Non-reversible left heart failureImminent risk of deathCandidate for cardiac transplantationFor both in-patient and out-patient useRecent FDA approval End Stage Heart FailureJanuary 2010Left Ventricular Assist DevicesMechanical Device

Surgically Implanted

Augments cardiac output or the ability to pump blood

Most common typeLeft-ventricular assist device (LVAD)

LVAD continuedOther typesRight ventricular (RVAD)Or in both ventricles (BiVAD)

Patients usually have an Internal Cardioverter-Defibrillator implantedHeart Mate II most commonOther models:HEARTWARE, JARVIC 2000, HEARTMATE XVE, and THORATEC PVAD/IVAD

Principles behind LVADBlood follows the normal path through the heart until it reaches left ventricle

Cannula placed in apex of the heart drains blood from left ventricle into system pump (internal)

Blood is then pumped into the aorta

Principle behind LVADDrive line (percutaneous cable) exits the abdominal wall, connecting internal pump to external controller

External ControllerBrains of the deviceContains settings, alarms and diagnostic information about the pump.Operates on battery or AC power

HeartMate IIComponentsTitanium blood pumpSystem controllerPercutaneous leadSystem monitor with display moduleAnastomosed to LV apex and ascending aortaPowered by base unit Portable batteries x 2 [12 hr]Emergency Power Pack [12 hr]

ApexTitanium PumpAscending AortaPerc LeadHeartMate IISpeed8,000 to 9,800 rpmsFlow3.3 to 7.8 liters/minSystem Controller microprocessor thatDelivers power to pumpControls pump speed and powerMonitors, interprets and responds to system performanceDiagnostic monitorHazard and advisory alarmProvides complete back-up systemEvent recording capabilitySpecial Care ConsiderationsAssessment of patient should be the same as any other patient with a few exceptions.

Be Careful not to cut, twist or bend the drive-line coming from the patients abdomen

Special Care ConsiderationsPatients will be on anticoagulant drugsASA, Coumadin, PlavixHigh risk of bleeding

Most Common ComplicationsBleedingNasal, gastrointestinal or intracranialThromboemboliPulmonary embolism, myocardial infarction or cerebrovascular accident

Patient ManagementInitial or Primary AssessmentOpen airway- interventions per protocolAssess breathing- interventions per protocolAssess circulation- control bleeding per protocol, assess skinAuscultate heart sounds to determine if pump is working. Listen at APEX of heart.If working: you will hear whirling soundPatient ManagementECG shows concerning arrhythmiaDo not intervene without consulting LVAD coordinatorIt is possible for them to present with VT or VF and be awake and talking If directed by LVAD Coordinator defibrillate/cardiovert as normalDont place pads over the device under the patients skin or implanted ICDNO CPR unless directed to by LVAD Coordinator!14Vital SignsYou will be unable to obtain a Pulse or Blood Pressure (manually)

Assessing mental status and skin will be the best indicator of oxygenation and perfusion.

Vital SignsAutomatic BP device may give you a reading. 60-90 mmHg acceptable (Doppler is most accurate, but not normally available on EMS Units)

Pulse Oximetry readings if obtainable, are unreliable due to weak or absent pulses.

LVAD AlarmingMake sure driveline and power sources(battery or AC power) are connected to the system controller

Contact LVAD Coordinator if possibleFamily or patient should have contact informationUtilize medical control if needed

LVAD Pump FailureContact LVAD coordinator for guidancePatient may decompensate rapidly or tolerate this condition well.

CAUTION!!!Restarting the pump is not recommendedIncrease risk of stroke or thromboembolism

DestinationPre-planning is key to success

Implant center should provide outreach training to local emergency responders when a LVAD patient is discharged to the communityPatients should have Emergency Binder with important information in regards to their care and the device

DestinationPrimary or Initial Assessment should reveal if there is a life threat.

Immediate life threat- transport to nearest most appropriate facility (contact medical control and LVAD coordinator for guidance if needed)

No life threat- coordinate destination with LVAD Coordinator

TRANSPORTKeep batteries and controller in reach and secured to the patient during transport

Keep them dry

Take the patients emergency travel bag, it has an extra controller, batteries and LVAD coordinators contact informationConclusionAs with any other special needs patient, your best asset will be referring to their caretakers if present. These patients usually call 911 for problems unrelated to their LVAD, so you shouldnt get distracted from your usual approach to patient assessment and treatment. Be sure to plan treatment regimen in coordination with LVAD coordinatorResourcesJournal of Emergency Medicine, Feb. 2012, No Pulse? (pg50-57)Useful websiteshttp://www.thoratec.com/videos/mp-vad-training.aspx?id=mp_hmII_profEduPro

http://www.mylvad.com/assets/ems_docs/00003528-2012-field-guide.pdf